Medicare AdvantageCoverageHigh impact
Upper and Lower Extremity Magnetic Resonance Imaging (MRI) - Medicare Advantage (Revised)
Humana·Orthopedics, Radiology, Sports Medicine +5 more·Medicare Advantage
Effective date
Jul 1, 2026
We identified it
Jul 2, 2026
Summary
Humana Medicare Advantage revised its MRI coverage policy for upper and lower extremities, establishing specific medical necessity criteria that must be met for coverage. Billing teams must now ensure that claims include documentation of a completed first-line imaging modality (ultrasound or x-ray) AND meet one of the listed clinical indications. This policy became effective July 1, 2026, and applies to Medicare Advantage members across all jurisdictions, with regional variations for specific MAC jurisdictions.
Action Required
By June 30, 2026: Billing team must update all systems and workflows to enforce the new MRI medical necessity criteria. SPECIFIC ACTIONS: (1) Configure billing software to require documentation of prior first-line imaging (ultrasound or x-ray) before CPT codes 73221, 73222, 73223, 73722, and 73723 will be accepted; (2) Create or update prior authorization templates in the billing system to include all listed clinical indications from the policy; (3) Update provider encounter forms and EMR templates to include checkboxes for documented first-line imaging completion and specific clinical indication documentation; (4) Train all billing and prior authorization staff on the 40+ covered indications listed in the policy, including post-surgical evaluations, trauma, bone infections, labral pathology, rotator cuff pathology, meniscal disorders, soft tissue masses, and osteomyelitis; (5) For initial imaging claims (suspected vascular malformation only), configure separate authorization pathway; (6) For jurisdictions JH and JL (Novitas MAC covering AR, CO, NM, OK, TX, LA, MS, DE, D.C., MD, NJ, PA), ensure compliance with applicable LCD L35391 for oncologic imaging. CONSEQUENCES: Claims lacking documentation of first-line imaging completion or failing to meet one of the specified clinical indications will be denied. Providers and billing staff must verify medical necessity before submission to avoid payment delays and claim rejections.